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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS oWNDR BUILDER DELCARATION <br />I hcrcby affirm undcr pcnalty of pcrjury thal I m cxcmpl fronl lhc Contraclors' l-iccnsc hw for thc folbwing rcumn (Scc.7031.5 ] <br />Busi[css aftl Profcs\trn Codc): Any City or County which rcquircs a Frmil lo construct. altcr. improvc, dcrrelish or rcpair any <br />structurc.priorloils issuance.alsorcquircslhcapplicantlbrsuchFrtrlilt)filcasigncdslatcrrcnt thalhcorshcisliccn(cd pursuanl <br />k) thc provisions of thc Conlracror's Licenscd ljw (Chaptcr 9. Commcncing with Scclion 7fi)0 of Division -1 of lhc Burincss a( <br />Prcltssioils Codc) or thdt hc or shc is cxcnrpl thcrcfrom and thc basis lbr lhc allcgcd cxcmplion. Any violation ofScclion 70-1 1.5 hy ani t <br />applicantforapcrmitsubjcctsthc applicanlloacivilpcnallyofnol,norclhanflvchundrcddollars($500). / <br />( <br />_1. as owncr of lhc pro1rcrly. or my cmployccs wilh wages as thcir s)lc compcnsation. will do lhc work and lhc structue is not t <br />inlcndcd oroffcrcdlbrsah(Se.TOl,l.BusincssandProfcssionsCodc:ThcConlrachr'sLicenschwdocsnotapplyloanowrcrof <br />thc pr)IEdy wlxr huilds or irnprovcs ttEcnr. and wlF d(Es such work hirnsclfor hcrsclfor thrrugh his or hs own cmployccs. <br />providcd that such improlcnrilts m nol iilcndcd or offcrc{ for sb. ll. howcrcr. thc huikling or irnprovcnrnt is $ld within onc )au <br />ofconrplction. thc Owncr l]uildcr will havc thc burdcn ofpmving thil hc or rhc did mt buikl or improve fie prefrcrly ti)r th! purlns of <br />sulc). <br />_1. as owncr of thc prolErly. an cxclusivcly conlrlcling wilh liccnscd contructors lo construcl lhr projcct (Scc. 7044. Busincss <br />ar}l Pnrli:ssionCodc:'lhcConlraclor'sLiccnscl-awdocsnolapplyloanowncrofpropcrlywhobuildsorinlprovcsthcrcon. <br />and who conlrucls li)r such projccts with a Corilraclo(s) liccnscd pursuanl to lhc Contrack)r's Liccnsc hw). <br />-latr|cxco|pl!ndcrsccti()n-.B.&P.C,ft)rlhisrcason.Dste:__ Owner: <br />WORKERS' COMPENSATION <br />DECLARATI(IN <br />I hcrchy affirnr undcr pcnalty of Frcrjury onc of lhc following dccluat ions: <br />-l <br />htrvcildwill mintainaCcnificaleoiConsenlloSel[-lnsurcforworkcrs'compcnsation.as pmvidcdforbySection3T0Oofthc <br />labor Grdc. for thc pcrforroncc ofthe work for which thc pcnnit is issucd. <br />-l <br />havc and will maintuin workcrs' compcnsalion insurancc. as rcquircd by Section J70O ofthc Labor Codc, tor thc pcrforroncc ol' <br />lhc work lbr which lhis ir issucd. My workcrs' conrpclsrlion insuruncc canicr antl lxrlicy nunrbcr ru'c: <br />uh- <br />l\rlicy ilt/tv'.7t <br />_l ccf,ily that in thc pcrli)rnmncc of thc work ii)r which this pcrmit is issucd. I shall not cnrphy any pcrson in any ilranncr <br />so rs kr hccoDrc subjcct k) lhc workcrs' conrpcrsation laws ofCalili)rnir. and agrcc lhat if I rhould hcconrc subjccl t) lhL <br />workcrs'coilrpcnsalionprovi\i(nlsofScclion-lTOOofrhcLahrrCorlc.lshall.fonhwilhcomplywilhthosprovisi(ns.. <br />WARNINC: Failurc k, scurc workcrs' conrpcnsattrn is unlawlul. and shall subjcct an cmphycr h ffintinal FEnaltics and <br />civil llncs up to onc hundrcd thousand dollars (Sl iil lo lhlxost of conrpcnsation. damgcs as provided for lhcZ./-Sccli()n <br />I hcrcby aflirm undcr pcnahy ofpcrjury that I am liccnrd undcr pnrvision r <br />o[ lhc Busincss and Proltssions Code. md my liccnrc is in tull forcc dd <br />9 (connmncing wilh Scction 7(D0) of Division .1 <br />l.iccn\c <br />'e#l ,r,*,,- /?37)Z <br />l)illc <br />(Z= <br />CONSTRUCTION LENDING AGENCY <br />I hcrchy allirnr undcr ;rcnally of Jrcrjury thul lhcrc is a conslruction hnding agcncy for thc lrcrfornrancc ofthc work l-or which this Jrcrmit ir <br />issucd (Scc. -1097, Civ. C.). <br />lrrtlcr's Nrrnc: <br />APPI ICANT DECI ARATION <br />I lmby affim undcr Jrcnulty of perjury onc of thc following declarations: <br />Dcmolition Pcrriils-Ashcsk)s Nolificalion Fcdcral RcSulalions (l illc 40. Ptrl6) <br />_Rcquircd kltcr of Notification <br />_l ccf,ify that lhc ltdcra! rcSulalions rcguding flshcstos rcnrvillilrc il)t applicablc to this projcct. <br />_l ccnify th.t I hrvc rcrd this alplication ilnd slalc th{t thc rtnvc inli,rnurlir[ is corccl. I ilFIcc k, eonr|ly wilh :rll ('ily i0d Counly <br />ordinilnccs and Slutc hws rchting to hcrchy xuthorizc rcprcscnlrlivcs of this Cily rnd County lo cntcr ufon lhc <br />ilh()v(: ilrcnlioncd p(,fcrly li)r <br />Applicanl or AgeDt <br />PemitE Dame (print): <br />' L-A .a L@! <br />,,r",37zo//g <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Salety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinos (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service [\/eter <br />FINAL <br />Notes, Remarks, Etc <br />'b7 <br />Dule: z <br />lrndcr's Ad&css: